© 2000 by European Society of Cardiology
SYNCOPE
‘The Italian Protocol’: a simplified head-up tilt testing potentiated with oral nitroglycerin to assess patients with unexplained syncope
1Cardiology Division, Ospedale Santa Maria Annunziata Firenze, Italy; 2Cardiology Division, Ospedale Civile Cento, Italy; 3Department of Cardiology, Ospedale San Filippo Neri Roma, Italy; 4Arrhythmologic Centre, Ospedali Riuniti Lavagna, Italy; 5Department of Cardiology, Ospedale San Pietro Igneo Fucecchio, Italy; 6Department of Cardiology, Ospedale Valduce Como, Italy; 7Department of Cardiology, Ospedale S Maria Nuova Reggio Emilia, Italy; 8Cardiology Division, Ospedale Civile Umberto I Mestre, Italy; 9Department of Cardiology, Royal Brompton Hospital London, U.K.
Abstract
Head-up tilt testing potentiated by sublingual nitroglycerin (NTG), advocated by an Italian group, is a simple and safe but still not a standardized, diagnostic tool for the investigation of syncope. In fact, owing to its rapid spread, the original protocol received, often arbitrarily, many subsequent modifications. We now define the best methodology of the test on strictly evidence-based criteria as: stabilization phase of 5 min in the supine position;passive phase of 20 min at a tilt angle of 60 degrees;provocation phase of further 15 min after 400 µg NTG sublingual spray. Test interruption is made when the protocol is completed in the absence of symptoms, or there is occurrence of syncope, or occurrence of progressive (>5 min) orthostatic hypotension. We intend that this protocol, named by us as ‘The Italian Protocol’, will be accepted as the standard methodology of the tilt test potentiated by sublingual nitrates.
Key Words: Syncope, tilt testing, nitrates
Correspondence: Angelo Bartoletti MD, Costa dei Magnoli 28 50125, Florence, Italy. E-mail: bartoletti{at}dada.it.
References
[1] Raviele A, Menozzi C, Brignole M, et al. Value of head-up tilt testing potentiated with sublingual nitroglycerin to assess the origin of unexplained syncope. Am J Cardiol 1995; 76: 267–272.
[2] Kenny RA, Ingram A, Bayliss J, Sutton R. Head-up tilt: a useful tool for investigating unexplained syncope. Lancet 1986; 1: 1352–1355.
[3] Fitzpatrick AP, Theodorakis G, Vardas P, Sutton R. Methodology of head-up tilt testing in patients with unexplained syncope. J Am Coll Cardiol 1991; 17: 125–130.
[4] Aerts A, Dendale P, Strobel G, Block P. Sublingual nitrates during head-up tilt testing for the diagnosis of vasovagal syncope. Am Heart J 1997; 133: 504–507.
[5] Natale A, Sra J, Akhtar M. Use of sublingual nitroglycerin during head-up tilt table testing in patients>60 years of age. Am J Cardiol 1998; 82: 1210–1213.
[6] Kenny RA, O'Shea D, Parry SW. The Newcastle protocols for head-up tilt table testing in the diagnosis of vasovagal syncope, carotid sinus hypersensitivity, and related disorders. Heart 2000; 83: 564–569.
[7] Del Rosso A, Bartoli P, Bartoletti A. Shortened head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope. Am Heart J 1998; 135: 564–570.
[8] Ammirati F, Colivicchi F, Biffi A, Magris B, Pandozi C, Santini M. Head-up tilt testing potentiated with low-dose sublingual isosorbide dinitrate: a simplified time-saving approach for the evaluation of unexplained syncope. Am Heart J 1998; 135: 671–676.
[9] Bartoletti A, Gaggioli G, Menozzi C. Head-up tilt testing potentiated with oral nitroglycerin. A randomized trial of the contribution of a drug-free phase and a nitroglycerin phase in the diagnosis of neurally mediated syncope. Europace 1999; 1: 183–186.
[10] Del Rosso A, Bartoletti A, Bartoli P. Methodology of head-up tilt testing potentiated with sublingual nitroglycerin in unexplained syncope. Am J Cardiol 2000; 85: 1007–1011.
[11] Raviele A, Giada F, Brignole M. Comparison of diagnostic accuracy of sublingual nitroglycerin test and low-dose isoproterenol test in patients with unexplained syncope. Am J Cardiol 2000; 85: 1194–1198.
[12] Benditt DG, Ferguson DW, Grubb BP. Tilt table testing for assessing syncope. J Am Coll Cardiol 1996; 28: 263–275.
[13] Kurbaan AS, Franzen AC, Bowker TJ. Usefulness of tilt test-induced patterns of heart rate and blood pressure using a two-stage protocol with glyceryl trinitrate provocation in patients with syncope of unknown origin. Am J Cardiol 1999; 84: 665–670.
[14] Foglia Manzillo G, Giada F, Beretta S, Corrado G, Santarone M, Raviele A. Reproducibility of head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope. Am J Cardiol 1999; 84: 284–288.
[15] Zaidi A, Benitez D, Gaydecky PA, Vohra A, Fitzpatrick AP. Haemodynamic effects of increasing angle of head up tilt. Heart 2000; 83: 181–184.
[16] Blumethal HP, Fung HL, McNiff EF, Tap SK. Plasma nitroglycerin levels after sublingual, oral and topical administration. Br J Clin Pharmacol 1977; 4: 241–242.
[17] Del Rosso A and Bartoletti A. Nitrate-stimulated test (letter). Am Heart J 1999; 137: 575–576.
[18] Brignole M, Menozzi C, Del Rosso A. Is the type of cardiovascular response during tilt table testing useful for the choice of the treatment? The new VASIS classification. Europace 2000; 1: 66–76.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  D. J. Hausenloy, C. Arhi, N. Chandra, A.-C. Franzen-McManus, A. Meyer, and R. Sutton Blood pressure oscillations during tilt testing as a predictive marker of vasovagal syncope Europace, December 1, 2009; 11(12): 1696 - 1701. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Developed in collaboration with, European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), and Heart Rhythm Society (HRS), Endorsed by the following societies, European Society of Emergency Medicine (EuSEM), European Federation of Internal Medicine (EFIM), European Union Geriatric Medicine Society (EUGMS), American Geriatrics Society (AGS), European Neurological Society (ENS), et al. Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC) Eur. Heart J., November 1, 2009; 30(21): 2631 - 2671. [Full Text] [PDF]
|
|
|
|
 |
|
 S. W. Parry, M. Norton, J. Pairman, M. Baptist, K. Wilton, P. Reeve, K. Sutcliffe, and J. L. Newton Impedance cardiography: a role in vasovagal syncope diagnosis? Age Ageing, November 1, 2009; 38(6): 718 - 723. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Flevari, D. Leftheriotis, C. Komborozos, K. Fountoulaki, N. Dagres, G. Theodorakis, and D. Kremastinos Recurrent vasovagal syncope: comparison between clomipramine and nitroglycerin as drug challenges during head-up tilt testing Eur. Heart J., September 2, 2009; 30(18): 2249 - 2253. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Marti-Almor, M. Cladellas, V. Bazan, C. Altaba, M. Guijo, J. Delclos, and J. Bruguera-Cortada Long-term mortality predictors in patients with chronic bifascicular block Europace, September 1, 2009; 11(9): 1201 - 1207. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S W Parry, P Reeve, J Lawson, F E Shaw, J Davison, M Norton, R Frearson, S Kerr, and J L Newton The Newcastle protocols 2008: an update on head-up tilt table testing and the management of vasovagal syncope and related disorders Heart, March 1, 2009; 95(5): 416 - 420. [Full Text] [PDF]
|
|
|
|
|
|
M. P. Tan, J. L. Newton, T. J. Chadwick, and S. W. Parry The relationship between carotid sinus hypersensitivity, orthostatic hypotension, and vasovagal syncope: a case-control study Europace, December 1, 2008; 10(12): 1400 - 1405. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. T. Timoteo, M. M. Oliveira, J. Feliciano, E. Antunes, M. N. da Silva, S. Silva, S. Santos, and R. Ferreira Head-up tilt testing with different nitroglycerin dosages: experience in elderly patients with unexplained syncope Europace, September 1, 2008; 10(9): 1091 - 1094. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. W. Parry, J. C. Gray, J. L. Newton, P. Reeve, D. O'shea, and R. A. Kenny 'Front-loaded' head-up tilt table testing: validation of a rapid first line nitrate-provoked tilt protocol for the diagnosis of vasovagal syncope Age Ageing, July 1, 2008; 37(4): 411 - 415. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Jastrzebska-Maj, K. Mizia-Stec, and D. Jakubowski Tilt testing potentiated with sublingual nitroglycerin in children with unexplained syncope Eur. Heart J., April 2, 2008; 29(8): 1074 - 1075. [Full Text] [PDF]
|
|
|
|
|
|
G. Foglia-Manzillo, F. Giada, N. Fteita, I. Nessi, M. Santarone, and A. Raviele Tilt testing potentiated with sublingual nitroglycerin in children with unexplained syncope Eur. Heart J., November 1, 2007; 28(21): 2605 - 2609. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Zysko, J. Gajek, R. Sciborski, J. Smereka, I. Checinski, and W. Mazurek The pattern of activation of the sympathetic nervous system during tilt-induced syncope Europace, April 1, 2007; 9(4): 225 - 227. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. van Dijk, F. Quartieri, J.-J. Blanc, R. Garcia-Civera, M. Brignole, A. Moya, W. Wieling, and on behalf of the PC-Trial Investigators Effectiveness of Physical Counterpressure Maneuvers in Preventing Vasovagal Syncope: The Physical Counterpressure Manoeuvres Trial (PC-Trial) J. Am. Coll. Cardiol., October 17, 2006; 48(8): 1652 - 1657. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Podoleanu, R. Maggi, M. Brignole, F. Croci, A. Incze, A. Solano, E. Puggioni, and E. Carasca Lower Limb and Abdominal Compression Bandages Prevent Progressive Orthostatic Hypotension in Elderly Persons: A Randomized Single-Blind Controlled Study J. Am. Coll. Cardiol., October 3, 2006; 48(7): 1425 - 1432. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Giada, I. Silvestri, A. Rossillo, P. G. Nicotera, G. F. Manzillo, and A. Raviele Psychiatric profile, quality of life and risk of syncopal recurrence in patients with tilt-induced vasovagal syncope Europace, January 1, 2005; 7(5): 465 - 471. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Raviele, F. Giada, C. Menozzi, G. Speca, S. Orazi, G. Gasparini, R. Sutton, M. Brignole, and for the Vasovagal Syncope and Pacing Trial Investi A randomized, double-blind, placebo-controlled study of permanent cardiac pacing for the treatment of recurrent tilt-induced vasovagal syncope. The vasovagal syncope and pacing trial (SYNPACE) Eur. Heart J., October 1, 2004; 25(19): 1741 - 1748. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Foglia-Manzillo, F. Giada, G. Gaggioli, A. Bartoletti, G. Lolli, M. Dinelli, A. Del Rosso, M. Santarone, A. Raviele, and M. Brignole Efficacy of tilt training in the treatment of neurally mediated syncope. A randomized study Europace, January 1, 2004; 6(3): 199 - 204. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Croci, M. Brignole, C. Menozzi, A. Solano, P. Donateo, D. Oddone, E. Puggioni, and G. Lolli Efficacy and feasibility of isometric arm counter-pressure manoeuvres to abort impending vasovagal syncope during real life Europace, January 1, 2004; 6(4): 287 - 291. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Sutton Editorial comment Europace, January 1, 2004; 6(5): 463 - 463. [Full Text] [PDF]
|
|
|
|
|
|
R. Garcia-Civera, R. Ruiz-Granell, S. Morell-Cabedo, R. Sanjuan-Manez, F. Perez-Alcala, E. Plancha, A. Navarro, S. Botella, and A. LLacer Selective use of diagnostic tests inpatients with syncope of unknown cause J. Am. Coll. Cardiol., March 5, 2003; 41(5): 787 - 790. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Donateo, M. Brignole, C. Menozzi, N. Bottoni, P. Alboni, M. Dinelli, A. Del Rosso, F. Croci, D. Oddone, A. Solano, et al. Mechanism of syncope in patients with positive adenosine triphosphate tests J. Am. Coll. Cardiol., January 1, 2003; 41(1): 93 - 98. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Occhetta, M. Bortnik, C. Vassanelli, and on behalf of the 'INVASY Italian feasibility Study The DDDR closed loop stimulation for the prevention of vasovagal syncope: results from the INVASY prospective feasibility registry Europace, January 1, 2003; 5(2): 153 - 162. [Abstract] [PDF]
|
|
|
|
|
|
M. Brignole, F. Croci, C. Menozzi, A. Solano, P. Donateo, D. Oddone, E. Puggioni, and G. Lolli Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope J. Am. Coll. Cardiol., December 4, 2002; 40(11): 2053 - 2059. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Raviele Tilt-induced asystole: a useful prognostic marker or clinically unrelevant finding? Eur. Heart J., March 2, 2002; 23(6): 433 - 437. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||